Summary.Introduction. Cardiac surgery with cardiopulmonary bypass (CPB) is commonly perceived as a risk factor for decline in renal function. Hypothermia, hypoxia, hypotension, non-pulsatile blood flow during CPB, use of ACE inhibitors, inotropic and (or) vasoactive support affects kidney and contributes to the acute kidney injury (AKI). Aim of the study. The purpose of this study was to evaluate the incidence, severity and outcome of CPB related AKI in children after open heart surgery. Materials and methods. We conducted prospective, non-randomized observational study at the tertiary care University Children's Hospital Pediatric ICU. We enrolled 30 patients, 12 boys and 18 girls with congenital heart disease (CHD). Their median body weight was 6,8 kg, (IQR 5,2<8,2 kg) and median age 7 months (IQR 5<10 months). SCr was determined and preoperative and postoperative creatinine clearance (ClCr) was estimated using Schwarz formula (eClCr). During surgical repair and till the end of the first 12 postoperative hours urine was collected to measure ClCr, using the difference in urine (UCr) and SCr concentrations (mClCr). Urine output, body temperature, duration of aortic cross clamping and cardiopulmonary bypass was recorded. Results. Median intraoperative urine output was 2,4 ml/kg/h (IQR 1,29<3,15 ml/kg/h). Median CPB time was 147 min., (IQR 116,75<205 min.), median aortic cross-clamping time was 95 min., (IQR 70,5<133 min.), cooling during CPB to 29,75°C. Postoperative SCr increased to 35 μmol/l (IQR 27,5<50,5 μmol/l) vs. preoperative SCr 29 μmol/l (IQR 24<32,9 μmol/l), P<0,0001. GFR declined from preoperative 98,4 ml/min./1,73 m2 (IQR 89,6<123,04) to postoperative 80,98 ml/min./1,73 m2, (IQR 60,73<97,97 ml/min./1,73 m2), P<0,0001. We find statistically significant difference (P=0,042) in measured 39,88 ml/min./1,73 m2 (IQR 21,96<67,82 ml/min./1,73 m2) versus estimated ClCr (eClCr) 80,98 ml/min./1,73 m2, (IQR 60,73<97,97 ml/min./1,73 m2). Observed prevalence of AKI was 46,6% (14/30 patients met KDIGO criteria for AKI). Conclusions. Open heart surgery in children has severe, but transient effect on expression of renal biomarkers. There was a marked difference between measured and estimated ClCr in our patients. Observed incidence of AKI was 46,6% (14 patients met KDIGO criteria of AKI from 30 of our patients). Before discharge from the hospital both biomarkers returned to normal values.

Sepsis remains one of the leading causes of morbidity and mortality in children despite improved understanding of the pathophysiology leading to better clinical management and survival. Recent studies have identified several areas that must be addressed by the clinician in order to continue to impact the morbidity and mortality associated with sepsis. In this review, we discuss the evidence in several of these areas including recognition of shock, initial resuscitation and fluid therapy, use of inotropes and vasopressors, identification and control of the source of infection, maintenance of oxygen delivery and ventilation. The overall goal is to provide the bedside clinician with an updated systematic approach to treat sepsis in children.

Intraabdominal Pressure in Children After Cardiothoracic Surgery Introduction. Intraabdominal pressure (IAP) now is widely recognized as an important variable and its monitoring is used in a variety of critically ill patients. Aim of the study. The aim of this study was to measure and to recognize the influence of various factors on IAP in children after surgical correction of congenital heart disease. Materials and methods. We conducted non-randomized, prospective observational study in Pediatric intensive care unitat a University Children's hospital. Study protocol was approved by Hospital Ethics commision. Measurements of IAP were performed in 15 children with mean body weight 8±5,83 kg, (Range 3,1-28 kg), mean age of 18,01 months (range 8 days-8 years) after cardiothoracic surgery. Cardiopulmonary bypass (CPB) was used in 12 patients. IAP was measured during first 24 hours postoperatively at 12 hour intervals via indwelling urinary catheter with bladder volumes of 1 ml/kg of normal saline. Of the 15 patients, 12 were mechanically ventilated at the time of the IAP measurements. Ventilation pressures: PIP (peak inspiratory pressure), MAP (mean airway pressure), PEEP (positive end expiratory pressure) and central venous pressure (CVP) via femoral vein were recorded. In some patients (6 from 15) amount of fluid evacuated via intraperitoneal drain from peritoneal cavity in first 24 hours was measured. Results. IAP was 12,24±3,54 mm Hg (Range 5,44-20,4 mm Hg), CVP 13±2,19, PIP 20±2,48 cm H2O, MAP 9±2,3 cm H2O, PEEP 5±1,35 cm H2O. Amount of fluid removed from peritoneal cavity during first 24 hours was 0,8±0,54 ml/kg/h (Range 0,04-1,7 ml/kg/h). Conclusions. We find elevated intraabdominal pressure (IAP> 12 mm Hg) in 10 from 15 (66,67%) pediatric patients in the first 24 hours after cardiothoracic surgery. There was a difference in IAP in patients with abdominal paracenthesis versus patients without the drain. The difference between groups was not statistically significant (P=0,4). We did not find a correlation between IAP, MAP and CVP. We, however, did not observe development of abdominal compartment syndrome (ACS).

Introduction. Cardiac surgery with cardiopulmonary bypass (CPB) is commonly perceived as a risk factor for decline in renal function. Hypothermia, hypoxia, hypotension, non-pulsatile blood flow during CPB, use of ACE inhibitors, inotropic and (or) vasoactive support affect kidney and contribute to the acute kidney injury (AKI).Objective. To evaluate incidence and outcome of AKI in children undergoing open heart surgery.Methods. We conducted a prospective, non-randomized observational study at the tertiary care of the University Children's Hospital Pediatric ICU. We enrolled 30 patients, 12 boys and 18 girls with CHD. Their median body weight was 6.8 kg (IQR 5.2 < 8.2 kg) and the median age was 7 months (IQR 5 < 10 months). SCr was determined and preoperative and postoperative creatinine clearance (ClCr) was estimated using the Schwarz formula. During surgical repair and till the end of the first 24 hours urine was collected to measure ClCr, using the difference in urine (UCr) and SCr concentrations. Urine output, body temperature, duration of aortic cross clamping and cardiopulmonary bypass were recorded.Results. Median intraoperative urine output was 2.4 ml/kg/h (IQR 1.29 < 3.15 ml/kg/h). Median CPB time was 147 min, IQR 116.75 < 205 min, median aortic cross-clamping time was 95 min, IQR 70.5 < 133 min, cooling during CPB to 29.75 °C. Intraoperative SCr rised to 35 µmol/l (IQR 27.5 < 50.5) vs. preoperative SCr 29 µmol/l (IQR 24 < 32.9), P < 0.0001. GFR declined from preoperative 98.4 ml/min/1.73 m 2 (IQR 89.6 < 123.04) to intraoperative 39.8 ml/min/1.73 m 2 (IQR 24.9 < 65.5), P < 0.0001. Observed incidence of AKI was 30% (9/30). We observed statistically significant (P = 0.006) inverse correlation (r = 0.522) between CPB time and ClCr.Conclusions. Open heart surgery in children has severe, but transient effect on expression of renal biomarkers. Observed incidence of AKI was 30% (9 from 30 of our patients). Before discharge from the hospital both biomarkers returned to normal values.

Communicated by Rafails RozentâlsAcute kidney injury (AKI)